Fibromyalgia: A therapeutic approach

Abstract

Goal: To review and systematize the recently published data about the therapeutic management of the fibromyalgic patient. Data sources: National Guideline Clearinghouse, Cochrane, Dare, Bandolier e Medline. Review methods: Search of guidelines, meta-analysis, systematic reviews and original studies written in english and portuguese, published between 1998 and September 2008, using the keywords: Fibromyalgia and Therapeutics. Recommendations of scientific societies were also searched and those in which the level of evidence was analyzed were selected. 2 guidelines, 3 meta-analysis, 11 systematic reviews and 4 original studies were included. SORT taxonomy was used to attribute the level of evidence and strength of recommendation. Results: The management of Fibromyalgia requires an assessment of pain severity, function, psychosocial context and associated morbidities. Regarding pharmacological therapy, there is strong evidence supporting the use of duloxetine, pregabalin and gabapentin for pain management. Moderate evidence supports the use of amitriptyline and cyclobenzaprine (specially if associated sleep disorders) and fluoxetine. Milnacipran and pirlindole showed promising results but further studies and needed. The positive effects reported with fluoxetine, duloxetine and milnacipran were independent of the presence of mood disorders and the dosages used were similar or higher than those recommended for antidepressive treatment, allowing the management of associated depression. As for non-pharmacological therapy, there is moderate evidence supporting aerobic exercise and heated pool treatment. Conclusions:Multiple pharmacological and non-pharmacological treatments showed positive effects in the control of pain and related symptoms. In the absence of a treatment that targets all the symptoms of fibromyalgia, an optimized management will require an individualized multidisciplinary approach.